Dorsal Approach to the Scaphoid

What it exposes. The dorsal approach gives direct visualisation of the proximal pole and the waist of the scaphoid — the segments most at risk of nonunion and avascular necrosis — and it is the only route from which a true antegrade (proximal-to-distal) headless compression screw can be placed centrally along the long axis of the bone. It also allows anatomic restoration of the articular surface and insertion of a bone graft into a dorsal trough when required. Why dorsal (and not volar). The dorsal approach is chosen whenever the target is the proximal pole or a nonunion: the entry point for an antegrade screw lies at the proximal pole, which is only safely accessible from the dorsal side. The volar (Russé) approach, by contrast, is the workhorse for distal pole and most waist fractures, where a retrograde (distal-to-proximal) screw avoids violating the trapezium and protects the dorsal blood supply. Indications: - Displaced proximal pole scaphoid fractures requiring open reduction and internal fixation

• Scaphoid nonunions, especially of the proximal pole and waist, requiring bone grafting
• Nonunion with avascular necrosis (AVN) of the proximal fragment requiring vascularised bone grafting
• Percutaneous antegrade (dorsal) screw fixation of minimally displaced proximal pole and waist fractures
• Proximal pole fragment excision for small comminuted unfixable fragments
• Scaphoid excision as part of salvage procedures (proximal row carpectomy, four-corner fusion) for SNAC or SLAC patterns Contraindications: - Distal pole or tubercle fractures — better accessed through the volar (Russé) approach; a dorsal antegrade screw would risk penetrating the trapezium or leaving the distal fragment unsupported
• Severe comminution of the dorsal ridge that would jeopardise the remaining blood supply if exposed
• Active infection of the dorsal wrist skin or septic arthritis
• Poor soft tissue envelope over the dorsum (relative — delay until recovered) Alternative approaches: - Volar (Russé) approach — the workhorse for distal pole and most waist fractures; uses a retrograde (distal-to-proximal) screw
• Lateral (radial) approach via the anatomical snuffbox — limited access to the waist and some percutaneous techniques; risks the radial artery and superficial radial nerve
• Arthroscopically assisted percutaneous fixation — for minimally displaced fractures where reduction is confirmed arthroscopically
• Combined dorsal and vascularised graft approaches (such as the 1,2 intercompartmental supraretinacular artery pedicled graft) — for recalcitrant nonunion with AVN

Position. The patient is supine with the affected arm extended onto a radiolucent hand table, a well-padded upper-arm tourniquet exsanguinated to a bloodless field, and the whole limb prepped and free-draped so the elbow and forearm can be moved. The wrist is positioned over a bolster or rolled towels so it can be flexed — flexion is what delivers the proximal pole dorsally. The surgeon sits at the head of the table with the hand resting palm-down (pronated). Fluoroscopy is essential throughout, for confirming guidewire position, screw length and central screw placement. The required views are posteroanterior, lateral, semi-pronated oblique, and the scaphoid-specific ulnar-deviated view. Surface landmarks. Lister's tubercle is the dorsal prominence on the distal radius; the 3rd extensor compartment (EPL) lies immediately ulnar to it and it marks the level of the scapholunate joint. The scapholunate interval is palpable just distal to Lister's tubercle, with the scaphoid lying radial and distal to it. Further landmarks are the radial styloid (radial extent of the wrist) and the base of the third metacarpal (distal landmark, in line with the longitudinal axis of the wrist and the scaphoid). The soft-tissue landmarks are the EPL tendon (palpable as it crosses from proximal-ulnar to distal-radial around Lister's tubercle toward the thumb), the EDC tendons (just ulnar to EPL), and the anatomical snuffbox (radial to EPL distally, containing the radial artery with the scaphoid waist at its floor). Incision. A longitudinal or gently curvilinear incision approximately 4 to 6 cm long, centred over the scaphoid just distal to Lister's tubercle and in line with the long axis of the third metacarpal. Longitudinal incisions are more extensile and heal well. Stay centred over the 3rd and 4th extensor compartments to avoid the radial artery (radial) and the dorsal sensory branch of the ulnar nerve (ulnar).

Work down through the layers centred just distal to Lister's tubercle: protect the dorsal sensory branch of the radial nerve, open the 3rd compartment and develop the inter-compartmental interval to the capsule, make a vessel-preserving capsulotomy, then flex the wrist to deliver the proximal pole.

Structures at risk, by layer

Tendon injury management. EPL irritation or rupture postoperatively is a recognised complication — consider retinacular reconstruction or an EIP-to-EPL transfer if rupture occurs. SBRN neurapraxia usually recovers; a symptomatic neuroma may require neuroma excision and burial. Extensile options. Extend proximally along the dorsum of the distal radius to expose the dorsal distal radius for combined distal radius and scaphoid fixation, or to harvest a pedicled dorsal vascularised bone graft such as the 1,2 intercompartmental supraretinacular artery (1,2-ICSRA) graft (continue to protect the dorsal capsular vessels and the 4th-compartment contents). Extend distally toward the base of the second and third metacarpals to expose the second and third carpometacarpal joints and dorsal metacarpals. For minimally displaced fractures, a dorsal percutaneous antegrade (Slade) technique avoids an open capsulotomy: the wrist is flexed over towels and a guidewire is introduced at the dorsal proximal pole and driven distally along the scaphoid axis under fluoroscopy. For recalcitrant nonunion with AVN, combine the dorsal approach with a vascularised bone graft (a pedicled 1,2-ICSRA graft, or a free medial femoral condyle flap for the most difficult cases); for SNAC or SLAC wrist salvage, extend into a standard dorsal wrist exposure for proximal row carpectomy or four-corner fusion. Closure principles. Repair the dorsal capsule with absorbable sutures without compressing the dorsal ridge vessels. Repair the 3rd-compartment retinaculum over the EPL (or transpose the EPL superficially) to prevent bowstringing and to glide the tendon smoothly — a well-repaired retinaculum reduces the risk of EPL adhesion and late rupture. Close in layers and apply a thumb-spica splint or cast. Intra-operative complications

Post-operative complications

Post-operative care. Apply a thumb-spica splint or cast, document SBRN sensation and digital perfusion, and elevate the limb. Rehabilitation: 0 to 6 weeks immobilisation in a thumb-spica cast or splint (longer for nonunion and grafting); 6 to 8 weeks radiographic union review with protected range of motion if healing; 8 to 12 weeks progressive strengthening as union confirms; and return to activity from 3 months once radiographic union is secure. Follow-up imaging is radiographs at 2, 6 and 12 weeks, with CT to confirm union when radiographs are equivocal (particularly after nonunion surgery) and MRI selectively to assess proximal pole vascularity in suspected AVN.

• Scaphoid fracture fixation — the principal operation done through this exposure.
• Open reduction and antegrade headless screw fixation of displaced proximal pole fractures.
• Percutaneous antegrade screw fixation of minimally displaced proximal pole or waist fractures.
• Bone grafting (cancellous or corticocancellous Matti-Russe dorsal trough) for scaphoid nonunion without severe AVN.
• Vascularised bone grafting — a pedicled 1,2-ICSRA graft for nonunion with proximal pole AVN, or a free vascularised medial femoral condyle flap for recalcitrant nonunion with AVN and humpback deformity.
• Proximal pole excision or scaphoid excision for an unreconstructable fragment, or as part of a dorsal wrist salvage exposure (proximal row carpectomy, four-corner fusion).

Guidelines, registries and global practice. Scaphoid fracture management is guided by international hand surgery consensus (IFSSH and FESSH), the AAOS appropriate-use criteria, and British Society for Surgery of the Hand guidance. The principles converge across examination systems: operative fixation for displaced and proximal pole fractures, anatomic reduction with central screw placement, vessel-preserving exposure, and vascularised grafting for nonunion with AVN.

Population evidence. Scaphoid fractures are the most common carpal fracture, with a lifetime risk that is highest in young active men. Nonunion risk rises with displacement and with proximal fracture location; proximal pole fractures carry the highest rates of nonunion and AVN. Central screw placement and anatomic reduction are the modifiable factors most consistently associated with union. Global practice variation. In high-resource settings, percutaneous and arthroscopically assisted fixation, vascularised pedicled and free flaps, and routine advanced imaging are standard. In resource-limited settings, the same biomechanical principles are achieved with open reduction and a standard headless screw, prolonged casting for stable patterns, and cancellous autograft for nonunion, with vascularised and arthroscopic techniques used selectively. Consent (globally applicable). Discuss nonunion and AVN (highest for proximal pole fractures), stiffness, the small risk of EPL irritation or rupture, SBRN numbness or neuroma, infection, and the possible need for revision or salvage surgery.